DISCUSSIONS WITH LEADERS

A Conversation Between Markus Schwaiger and Johannes Czernin

Markus Schwaiger1 and Johannes Czernin2

1Technische Universit¨at M¨unchen, Munich, Germany; and 2David Geffen School of Medicine at UCLA, , California

my research career with an interna- Markus Schwaiger has been Medical Director at the univer- tional stipend, which allowed me to sity hospital ‘‘Klinikum rechts der Isar’’ of the Technical Univer- spend 1 year in Cincinnati (OH) sity of Munich (TUM) since 2016. From 1993 to 2017 he was working in physiology. This 1-year Director of the Clinic and Polyclinic of Nuclear Medicine. His fellowship initiated my interest in main area of research is the use of multimodal imaging to visu- cardiovascular sciences, because I alize and quantify biologic processes. His research involves the studied the vascular effects of hista- use of PET in cardiology and oncology. He is Director of the mine in the mesenteric circulation. German Research Foundation’s Collaborative Research Center After returning to Germany I started 824, which deals with molecular imaging for selecting and mon- out as a cardiac surgeon—but not for itoring oncologic therapies. Diagnosis and treatment of thyroid long. I switched over to cardiology endocrine and neuroendocrine diseases are also of special interest. and began a combined program of Markus Schwaiger, Dr. Schwaiger studied medicine at Freie Universit¨at Berlin and internal medicine and cardiology at MD Freiburg University. His career as a doctor and researcher has the German Heart Center in Munich. Dr. Czernin: taken him to the University of California Los Angeles (UCLA) And this is when your research career started? School of Medicine and the University of Michigan (Ann Arbor), Dr. Schwaiger: I started in the area of nuclear cardiology with radio- as well as other academic sites. He is a member of the Bavarian nuclide ventriculography (RNV) and myocardial scintigraphy. At that Academy of Sciences and the Deutsche Akademie der Naturforscher time, RNV was the only method to measure cardiac function noninva- Leopoldina. He has an honorary doctorate from the University of sively, so as a young cardiologist I was quite excited. Subsequently, the Varna, Bulgaria. role of myocardial metabolism attracted my attention, because we became Dr. Czernin: I want to start out with a bit of your biography. interested in learning how the mechanical performance of the heart was You studied medicine at the Freie Universit¨at Berlin in the 1960s. supported by energetics. I was told that there was a new ‘‘machine’’ in the That was at a time when many people would not have focused on that allowed noninvasive measurement of cardiac metabo- studying but instead were on the streets demonstrating. What was lism. This was the beginning of cardiac PET. I went to UCLA to visit the climate at the university at that time? Heinz Schelbert and became extremely excited about emerging research 18 11 Dr. Schwaiger: It was definitely a climate of change. The Ger- possibilities using metabolic imaging with F-FDG and C-palmitate. I man so-called ‘‘68 movement’’ was a primarily student-driven re- must admit I was even more enthusiastic about the idea of living in action against the authoritarian structures of German society in Westwood near Santa Monica. Retrospectively, my decision to move to general and in particular against the rigid structures at universities. LA turned out to be a very positive step, because, as you know, UCLA Discussions focused on liberation from traditional, hierarchic struc- has been an outstanding environment for many young German car- tures, following mostly left-wing ideologies. This political reorienta- diologists. I had access to new resources we did not have at home. In tion was part of the German recovery process from the Hitler regime addition, the academic freedom at American universities, along with and World War II. At the university level, students petitioned to be the support and excellent training provided by leaders in the field, part of academic decision-making bodies defining areas and content represented an ideal start for my research in cardiovascular imaging. of curricula. It was a very interesting and challenging time for me Dr. Czernin: And then you did all the pivotal early viability personally, coming from a well-preserved bourgeois environment in studies with Heinz? Munich. We all needed to define our own political position in very Dr. Schwaiger: I learned to do animal experiments in Cincinnati, unstable times. Retrospectively, it is important to note that the student because we worked on the functional characterization ofhistaminere- protests started off many reforms in German society and universities. ceptors in dog models. So I was quite familiar with experimental models Maybe the students were a little bit too loud at the time, but the and enjoyed combining preclinical with clinical research. When I started results had significant impacts on democratic processes in Germany. at UCLA, I wanted to use PET imaging to characterize experimental Dr. Czernin: What happened after medical school? models of ischemia and reperfusion. This was the time when recanaliza- Dr. Schwaiger: I moved back to Munich, where I was born. I tion of the coronary arteries in the setting of acute myocardial infarction did my early clinical training there and completed my doctoral became the favored strategy to rescue myocardial tissue. The pioneering thesis on vector electrocardiography. During that time, I started research of Dr. William Ganz in this area at Cedars-Sinai (Los Angeles, CA) inspired me to follow this direction. We hypothesized that PET imaging would be useful to predict myocardial recovery after tran- COPYRIGHT © 2019 by the Society of Nuclear Medicine and Molecular Imaging. sient ischemia. Indeed, we observed that increased 18F-FDG uptake in

DISCUSSIONS WITH LEADERS • Schwaiger and Czernin 573 ischemic areas was a signal of viability, as evidenced by subsequent environment in which everyone must have insurance coverage. The functional recovery. This experimental work was part of a larger research ‘‘hybrid’’ German system also includes private insurance for high-income program at UCLA that defined the role of PET in clinical identification groups with broader coverage. The bottom line is that everybody has free of viable myocardium in the setting of advanced ischemic heart disease. choice of physicians and access to all aspects of the German health care Dr. Czernin: After a long and very fruitful collaboration with system without restrictions. On the other hand, German health care Heinz Schelbert you left UCLA in 1987 and moved to Michigan. providers face the problem that services are ‘‘capitated.’’ This means that Dr. Schwaiger: This was a difficult decision, because I really physicians and hospitals work within predefined budgets that are nego- enjoyed UCLA and I had just finished my cardiology fellowship there. tiated with insurance companies. The result of this capitation is that the I was offered a position in the Division of Cardiology and Nuclear cost of German health care is about half that in the United States. The Medicine. But at the same time I felt that it might be better for me to system is efficient, but resources are restricted, especially for academic start my own independent research group. At this time, Michigan ex- institutions. For example, the role of clinician scientists at academic celled with a very prominent cardiology program headed by Dr. Bertram centers is much less developed than in the United States. At German Pitt. Dr. Eric Topol, Dr. Cindy Grines, and many others were recruited to institutions research is usually done after hours, because physicians are focus on innovative ways to treat acute myocardial infarction. This was primarily engaged in clinical services. In addition, structures in German scientifically a very exciting time, because cardiology changed from a academic institutions are quite hierarchic. Each department is directed by conservative to a very ‘‘aggressive’’ discipline based on intervention in 1 chair, and everyone else serves this chair. This leads to a much more treatment of coronary artery disease. We were all excited to be part of vertical organization than in the United States. The advantage is, I have to the rapid changes leading to interventional cardiology. Nuclear cardiol- admit, that one has a high degree of freedom when at the top of this ogy was in many aspects an important part of this process. hierarchy. In recent years, several changes have been made to adapt the Dr. Czernin: You stayed there for 6 years and were then offered German structure to the increasing need for protected research time. the chair position at the Department of Nuclear Medicine at TUM. Overall, I think both the U.S. and European systems have their Dr. Schwaiger: I had the opportunity to go back to Munich. strengths and limitations as far as research is concerned. However, After many discussions, we decided as a family to return to Ger- I am convinced that the United States provides a more attractive many. I was very optimistic about taking all of my very positive academic environment, whereas Europe excels in very efficient experience in the United States back to Europe. overall health care for most members of society. Dr. Czernin: This leads us to the focal point of the discussion that Dr. Czernin: When you talk about capitation in Germany what I would like to have with you. In Munich, you served as chair, then do you mean? The patient has insurance, and he or she has to pay became dean of the medical school in 2002 and medical director of into this system.

``Overall, I think both the U.S. and European systems have their strengths and limitations as far as research is concerned. However, I am convinced that the United States provides a more attractive academic environment, whereas Europe excels in very efficient overall health care for most members of society.’’

the hospital in 2017. This is the time lapse version of your career in Dr. Schwaiger: When I say ‘‘capitated’’ I am not talking about Munich. You got to know 2 different health care systems intimately: an individual patient. I am talking about services provided by hos- the one that we have in the United States versus the European system pitals and physicians. Each year a hospital is assigned a budget and that is often characterized as ‘‘socialistic’’ in the United States. In must predict how many patients will likely be seen and how many your view, what are the advantages and disadvantages of both sys- services will be provided. If the numbers of patients exceed the tems? In particular I want to ask you this question because you are agreed-on limit, the hospitals and physicians do not receive 100% now in a leadership position in administration. which I think gives you reimbursement for those patients—only a certain percentage. That an entirely different view of how health care can and should be done. means that physicians are primarily paid for a fixed budget and are Dr. Schwaiger: This can only be answered by comparing European not expected to exceed the predicted patient numbers or agreed-on with American histories, leading to different models of health care sys- number of services. tems. The American concept of a ‘‘fee for service’’ system resulted in Dr. Czernin: That is kind of the dream world for utilization excellent medical care at leading academic institutions. This is what I review boards: where you have an almost natural system that limits appreciated as an academically oriented physician, because there was no what can be spent—and if you overspend, it costs you. What I shortage of resources. At UCLA, there was a superb research infrastruc- always find fascinating is that, even with the so-called restrictions ture matched by large departments serving most medical subspecialties. that you have in the supply of health care, overall survival is still What I experienced to be very attractive about this system was the better than in the United States. Part of that is, of course, attribut- opportunity to do clinical work as well as research. However, these able to the socioeconomic structure here in the United States. almost luxurious conditions are somewhat offset by the societal point Dr. Schwaiger: There are important differences between Ger- of view. The entrepreneurial health care structure represents a very ex- many and the United States. Germany is a much smaller country pensive system. Because medical insurance coverage is limited, the with a much more homogeneous population. In addition, there is a advantages of this system are accessible to only part of society. Under- long tradition of mandatory insurance coverage. The German system privileged members of the society have only limited access. In contrast, is not a ‘‘public health care system’’ like that in Great Britain. It is a Germany has a relatively ‘‘social’’ health care system, which works in an health care system financed by insurance carriers, competing with

574 THE JOURNAL OF NUCLEAR MEDICINE • Vol. 60 • No. 5 • May 2019 each other for good services. However, the extent of services is Dr. Czernin: There must be something different about the people defined by a central agency operated and financed by the Ministry who enter the field in Germany versus the United States. Because I of Health. For example, this agency defines reimbursable indications think one must have a very special drive to work until 10:00 or for PET. In contrast to most countries, PET is only covered for a few 11:00 at night and really develop this keen interest in research. indications as an outpatient service. Use of PET is controlled by Dr. Schwaiger: If you look at high achievers in the United primarily allowing hospitals to perform an agreed-on number of States, they work pretty hard, too. I think you have more resources PET scans. The government is very concerned that expensive diagnos- at academic institutions in the United States, and, in most in- tic methods are overutilized, primarily in the outpatient setting. This stances, you can decide how much time you want to spend in has led to a much more restrictive regulation of PET as compared with research and how much time in clinical work. We are fighting other countries in Europe and the United States. right now for a ‘‘clinician scientist program,’’ which allows up Dr. Czernin: There’s a second aspect that I think is sometimes to 1 year of protected research time during training as a specialist. forgotten here in the discussion, and that is that every citizen, of However, this time is currently not recognized for board certifica- course, can purchase his or her own extra private insurance. What tion. So, as I recall, in the United States you can do 1 year of percentage of people do that—10% to 20%? research fellowship during training. A similar program is just Dr. Schwaiger: Fifteen percent to 20%. But you must have a starting in Germany now. We want research fellowships to be certain minimal income to be eligible for private insurance. In western considered part of medical training. Germany, it is about 15% to 20%, in east Germany it is less than 10%. Dr. Czernin: So here you have 4 months of research time during Dr. Czernin: There is another misconception in the United the 3-year training. States about the European health system. It is often believed here Dr. Schwaiger: This is very much needed in Germany, espe- that health care is free in Europe. And I think it’s important to cially in times when translational research is growing. I see increas- explain to the readers that, of course, health care is not free. ing challenges to match good clinical training with the growing Dr. Schwaiger: This is not that different compared with the demand for competitive research in medicine. United States. However, the cost of insurance is split between Dr. Czernin: Maybe there’s another argument for why you have employer and employee. The providers bill insurance companies, these really ambitious people. In Germany you have to become the which cover the health care costs. chief to really be free. You can only become the chief if you have Dr. Czernin: I just wanted to make sure that we understand that the track record that shows that you are qualified academically. it is not free. Dr. Schwaiger: I recently attended a meeting of German aca- Dr. Schwaiger: Not at all. We do not have a ‘‘nationalized demic medical centers. One intensely discussed question was how health care system’’ like in Great Britain. we could become internationally more competitive. There was con- Dr. Czernin: Despite the high clinical workload you described sensus that we have to develop a career path for young physicians to before that leaves residents and fellows as well as faculty much less support their pathway to independent investigator status by provid- time for research, you created a highly successful research environment. ing time and resources. It would be an effective means to overcome How is that managed when you cannot really pay people for that? the existing hierarchic system with only few positions at the top of Dr. Schwaiger: The situation has changed in Germany during the the organization. For the younger generation of physicians, it is just past 20 years, because grant support has increased substantially. Cur- not attractive enough if a limited number of leadership positions are rently, it is easier to obtain grant support in Germany than in the United available. There is increasing awareness about needed changes at States. In Germany, the funding rate is between 20% and 30%. As I university hospitals to attract and keep the best people in academia. understand it, the funding rate in the United States is about 10%. Dr. Czernin: So when you narrow this discussion down a little bit Research funding is also distributed throughout the European Union, to nuclear medicine, there is actually no question that Germany, The and especially the European Research Council (ERC) represents a very Netherlands, , and, of course, the Scandinavian countries are important agency supporting individual scientists throughout Europe. highly competitive, because most of the new developments really come Typical ERC grants amount to V2–3 million over a time period of 5 from Europe. So it is an interesting paradox that great successes have years. So, yes, it is more an issue of research time and resources and come from an environment in which it is really not so easy. less of a funding issue. Still, it remains difficult to combine research Dr. Schwaiger: Additional factors reflect the role of nuclear with a clinical career, mainly because of a limited number of professor medicine in Europe. Nuclear medicine is an independent subspe- positions available at German academic medical centers. cialty in Germany and most European countries. So it is an entity Dr. Czernin: The improved funding is good news for now. But that was always considered as innovative and very technically ori- you were able to create a successful research program before this ented. Nuclear medicine was driven not only by physicians but infrastructure was created. also by physicists and chemists. Nuclear medicine was initially Dr. Schwaiger: The only way I could do it was because I was placed in internal medicine and endocrinology. Because of very able to raise grant money. In addition, I always had about 20% to strict radiation protection laws in Germany, it always had its own 30% nonmedical scientists in our research group. Nuclear medi- inpatient clinical service in hospitals. So it is considered an in- cine allows the recruitment of nonmedical research personnel be- dependent subspecialty like internal medicine or surgery, serving cause of its tradition in medical physics and radiochemistry. This not only diagnostic but also therapeutic services. This is in con- gave me the freedom to develop an interdisciplinary group of trast to radiology, which has no inpatient resources of its own. scientists. I have been quite privileged to work with very talented Dr. Czernin: I also think that the business model makes a big physicists and radiochemists during recent years. difference, again because you do not have to generate profits. In Dr. Czernin: You raised funds through foundations? the United States we are supposed to have, as a worst-case sce- Dr. Schwaiger: Yes. Foundations and donor money exist, and at nario, a balanced budget—and usually are supposed to generate Bavarian universities there is basic support that can actually be surplus. And this is difficult to do with nuclear medicine, because invested in research personnel and infrastructure. it is not a volume-based business.

DISCUSSIONS WITH LEADERS • Schwaiger and Czernin 575 Dr. Schwaiger: You would be surprised! With increasing reimburse- many small subunits or sections. Often, such subunits are driven ment for radionuclide therapies nuclear medicine is one of the more by self-interest, and these self-centered strategies must be over- profitable units at our hospital. Not only thyroid and neuroendocrine come. The challenge is to find the right balance so that people are therapies but also prostate therapy are currently well reimbursed. The happy and can identify with their own areas. On the other hand, emerging role of theranostics will definitely change the role of nuclear they need to recognize that they are part of a large organization. In medicine in oncology. It remains to be determined whether nuclear med- my opinion, this organizational balance is the key to creating ideal icine will be able to maintain leadership in the application of radionuclide structures at academic medical centers. therapy. This leadership can only be secured by continuing innovation. Dr. Czernin: So if I understand you correctly, you are for col- Dr. Czernin: So that is what I was getting at. There is, of laboration and integration. Barriers that are unnecessary should be course, a great new opportunity in the United States, because removed. But you wouldn’t want to close small entities. This is bring- theranostics can really change the business model for nuclear ing us back to nuclear medicine: you mentioned chemists, radio- medicine. This may change the way nuclear medicine is managed chemists, biologists, and physicists who work in nuclear medicine. in the United States. We suddenly have more applicants for resi- I think it’s unfortunate and counterproductive if these individuals are dency positions, for example. So something positive is happening. administratively under, for example, a radiology department. Let me get back to your career. You went from leading very small Dr. Schwaiger: I agree with you. Nuclear medicine or molec- units to increasingly larger units—as chair of a department to being ular imaging has its own culture, which we need to preserve and dean of a school of medicine and now leading an entire hospital as exploit. Of course, we also have to make sure that we do not have medical director. How did that change your view of leadership? to buy 3 PET/CT units, 2 for radiology and 1 for molecular im- How do structures within the larger system work best, indepen- aging. The overriding strategy must be that we support the most dently or in concert with other units? How do you best foster a efficient patient services. From an organizational point of view, system in which people have incentives to become successful? nuclear medicine and radiology have to deliver an integrated clin- Dr. Schwaiger: Yes, it is much more difficult to reach individual ical service. On the other hand, they should remain independent in people when you increase your responsibilities. Time becomes much research and development. more valuable. Of course, when you have a group of 20 people, then it Dr. Czernin: Markus, what are your plans for the next 5 years? is much easier to interact personally. You have much more direct Dr. Schwaiger: I will probably be in my current position for contact, and you can motivate people more easily. When you are another 3 years. During this time, I hope to develop more interdis- moving upward, the most challenging aspect is how to communicate ciplinary strategies with our colleagues in engineering. For example, your ideas. You have to be much more formal and use measures that I am excited about introducing robotics into clinical care and using motivate indirectly. This means you need to have various levels of imaging to guide these robots. I see a future that includes minimally supporters to get your ‘‘message’’ heard. This just requires a different invasive interventions, coupled with precise imaging procedures that way of interacting. Overall, though, I believe that the incentives are define various characteristics of the body, including ‘‘molecular pretty much the same. Individuals want to be recognized as an impor- sensing.’’ I see the role of imaging as an advanced support system tant part of an organization and expect you to value their contributions. for interventions. The emerging new techniques in computer science Dr. Czernin: This series is called Discussions with Leaders. and data analysis (artificial intelligence, machine learning) allow us How would you define leadership? to perform a new kind of medicine that I would like to stimulate in Dr. Schwaiger: It is most important to have a defined strategy in our center. We have just founded a big center for robotic medicine at order to lead an organization. The second step is to convince your the TUM combining robotics and sensing. staff and colleagues to follow your direction. In most cases, this Dr. Czernin: Do you also focus on artificial intelligence? cannot be achieved with a top-down strategy that forces people to Dr. Schwaiger: I don’t use this word because I think it’s quite follow you. In my opinion, the most successful approach is if you overused. But I believe that there are new methods to handle large motivate your staff to voluntarily take the direction in which you datasets in a very condensed time frame. Yes, artificial intelligence will want them to go. Currently, I put most of my energy into convincing change the way we apply our technologies. Especially, imaging and people that a change of old-fashioned processes will contribute to artificial intelligence will be a nice and tight package. One emerging idea overall better success for our hospital. The introduction of ‘‘digital is to generate an ‘‘electronic twin’’ for a given patient. We could integrate medicine’’ is a motor and motivation for change. One of my major all the available information and then use this twin to plan interventions goals in Germany is to decrease hierarchic steepness in our system. and predict response to therapy. Knowing the genetic and structural Second, I am focusing on measures to overcome the rigid organiza- makeup of a specific patient, you may be able to test certain pharma- tion in subspecialties. I try to support structures leading to more ceutical interventions using this electronic twin. We are seeing very interdisciplinarity and interprofessionality. As we are part of the exciting developments in which our tools match the real and electronic TUM, we have the opportunity to import many ideas from engineers, worlds. I am convinced we will find useful applications for this match. physicists, and computer scientists into the daily work of our hospital. Dr. Czernin: Do you have anything else that you want to tell us? Coming back to my background in nuclear medicine, I guess the Dr. Schwaiger: You were talking about my experience in 2 success of nuclear medicine is a reflection of interdisciplinary systems. What I really learned in the United States is beyond research. Without chemists, radiochemists, physicists, and others, the health care system. It is the positive and very optimistic view nuclear medicine would never be where it is right now. Many aspects of technologic progress. It is all about the challenge to shape the of progress in biology were and are dependent on the introduction of future. I learned to combine this attitude with the more critical and new technologies. Creating an open interdisciplinary culture is one of careful evaluation of reality that characterizes the European sys- the goals of the TUM as a measure of scientific competitiveness. tem. I think this mix has served me very well. So to close from my Dr. Czernin: Do you still believe in department structures? side: I feel very privileged to have been able to work in both Dr. Schwaiger: Yes, I do. But I also believe that we have to systems, in the United States and Europe. overcome some of the limitations created by the existence of too Dr. Czernin: Thank you very much, Markus, for your time.

576 THE JOURNAL OF NUCLEAR MEDICINE • Vol. 60 • No. 5 • May 2019